Chia-Cheng Lee

Emergency stapled haemorrhoidectomy for haemorrhoidal crisis

Between January 2000 and December 2002, 30 consecutive patients with acute haemorrhoidal crisis were recruited. All patients gave written informed consent and were operated on by the same surgeon. Exclusion criteria included previous perianal surgery, other anorectal disorders, pregnancy and severe medical problems. All patients underwent stapled haemorrhoidectomy under local anaesthesia within 24 h of admission. Stapled haemorrhoidectomy was performed with the PPH TM set (Ethicon Endo-Surgery, Cincinnati, Ohio, USA), using the standard method reported by Longo1 (Fig. 1) modified by placing the purse-string suture closer to the dentate line (3 cm from anal margin) . Patients were instructed to complete a preoperative and postoperative subjective pain survey using a visual analogue scale ranging from 0 (no pain) to 10 (the worst pain ever experienced). Data were entered into a statistical database (SPSS version 12·0; SPSS, Chicago, Illinois, USA). Descriptive statistics were used for demographic data and operative outcomes. The χ2 method was used to test categorical variables. Trend analysis was performed to examine the progressive mean pain scores of the 30 patients. P < 0·050 was considered statistically significant.

Rare complication following screening colonoscopy: Ischemic colitis

Ischemic colitis is the most common form of gastrointestinal ischemia, accounting for more than 50 percent of cases. The risk factors for ischemic colitis are numerous. To confirm the diagnosis, colonoscopy is the gold standard. However, some case reports have indicated the procedure itself may be a risk factor for ischemic colitis. Because of the rarity of this condition, the definite mechanism responsible for colonoscopy-induced ischemic colitis is debated. We report on a man with no risk factors for ischemic colitis who underwent screening colonoscopy. Before the procedure, the patient was advised to drink sodium phosphate (45 mL Fleet Phospho-soda; C.B. Fleet Company, Inc., Lynchburg, VA, USA) in 500 mL of a soft drink twice. During the procedure, a dry, wan mucosa was observed in the descending colon (Fig. 1A). Mild periumbilical pain and repeated bloody diarrhea developed several hours later. Abdominal computed tomography with contrast showed edematous wall thickening from the rectum to the transverse colon but no evidence of fluid accumulation in the peritoneal cavity (Fig. 2). Ischemic colitis was diagnosed by emergency colonoscopy (Fig. 1B). The patient received conservative treatment with fluids, peripheral parenteral nutrition, and i.v. antibiotics. The patient recovered fully 7 days after admission. In 1990, Wheeldon and Grundman first described a patient with systemic lupus erythematosus (SLE) who developed the complication of ischemic colitis after colonoscopy. Since then, only a few cases have been reported. We consider that intravascular volume depletion was the most probable predisposing factor. Moreover, our patient underwent the procedure without anesthesia. Abdominal discomfort and anxiety may cause contraction of blood vessels, which can lead to ischemic colitis. We observed the wan, dry mucosa during the screening colonoscopy. This may suggest ongoing ischemic changes in the colon mucosa. When observing this sign during the procedure, immediate hydration may prevent the progression to ischemic colitis.

Adjuvant chemotherapy with tegafur/uracil for more than 1 year improves disease-free survival for low-risk Stage II colon cancer

Background It is uncertain whether adjuvant chemotherapy (CMT) improves survival in patients with low‐risk Stage II colon cancer. We aimed to determine the disease‐free survival (DFS) and 5‐year overall survival (OS) of low‐risk Stage II colon cancer patients treated with adjuvant tegafur/uracil (UFUR). Methods From January 2004 to December 2011, the follow‐up status of 278 low‐risk Stage II colon cancer patients who underwent surgery in a single medical center was retrospectively analyzed. These patients were divided into three groups based on whether they received adjuvant CMT with UFUR, adjuvant CMT with 5‐fluorouracil, or surgery alone. DFS and 5‐year OS curves were calculated using Kaplan–Meier survival analysis and Cox proportional hazards regression. Results In the study population, including 278 low‐risk Stage II colon cancer patients with a mean age of 68.28 ± 13.01 years, 132 (47.5%) received adjuvant CMT with UFUR, 49 (17.6%) received adjuvant CMT with 5‐fluorouracil, and 97 (34.9%) underwent radical surgery alone. At 5 years, the adjusted DFS and OS of low‐risk Stage II colon cancer patients were 85.5% and 81.8%, respectively, in the surgery alone group and 97.9% and 96.2%, respectively, in the surgery plus UFUR > 12 months group (p = 0.004 and p = 0.098, respectively). In multivariate analysis, CMT with UFUR for more than 12 months increased DFS over surgery alone. There was no statistical difference in the 5‐year OS. Conclusion Adjuvant CMT treatment of low‐risk Stage II colon cancer patients with UFUR for more than 12 months following surgery improves DFS over surgery alone.

Sebacoyl Dinalbuphine Ester Extended-release Injection for Long-acting Analgesia: A Multicenter, Randomized, Double-blind, And Placebo-controlled Study in Hemorrhoidectomy Patients

Objectives: This study was conducted to evaluate the safety and efficacy of single sebacoyl dinalbuphine ester (SDE) injection (150 mg/2 mL) when administered intramuscularly to patients who underwent hemorrhoidectomy for postoperative long-acting analgesia. Methods: A total of 221 patients scheduled for hemorrhoidectomy from 6 centers in Taiwan were randomly divided into SDE group and placebo group, and received the treatment, vehicle or SDE, 1 day before the surgery. Visual analogue scale (VAS) was recorded up to 7 to 10 days. Pain intensity using VAS AUC through 48 hours after surgery was calculated as the primary efficacy endpoint. Results: Area under the curve of VAS pain intensity scores (VAS AUC) through 48 hours after hemorrhoidectomy was significantly less in SDE group than those in placebo group (209.93 vs. 253.53). VAS AUC from the end of surgical procedure to day 7 was also significantly different between SDE and placebo group (630.79 vs. 749.94). SDE group consumed significantly less amount of other analgesics, such as PCA ketorolac and oral ketorolac. Median time from the end of surgery to the first use of pain relief medication was also shortened in the placebo group than in the SDE group. Most adverse events were assessed as mild and tolerable in both groups. Discussion: SDE injection demonstrated an extended analgesia effect, with a statistically significant reduction in pain intensity through 48 hours and 7 days after hemorrhoidectomy.

Oral tegafur-uracil as metronomic therapy following intravenous FOLFOX for stage III colon cancer

The purpose of this study was to estimate the impact of metronomic therapy with oral tegafur-uracil (UFUR) following an intravenous FOLFOX regimen as surgical adjuvant chemotherapy on the overall survival (OS) and disease-free survival (DFS) of stage III colon cancer patients. From the retrospective database of patients who underwent a surgical resection for colorectal cancer at the Tri-Service General Hospital from October 2008 through December 2014, stage III colon carcinomas treated with radical R0 resection were reviewed. One hundred thirty two patients were treated with a FOLFOX regimen (comparison group), and 113 patients were treated with the same regimen followed by additional oral UFUR (UFUR group). The clinical characteristics and mean age of the comparison and UFUR groups were similar. Furthermore, for all study patients, DFS was not significantly different between the two groups. However, 5-year OS rates were 86.8% and 68.5% in the UFUR and comparison groups, respectively (p = 0.0107). Adding UFUR to a FOLFOX regimen was found to significantly improve the OS in patients with stage III colon cancer. UFUR as a maintenance therapy following FOLFOX regimen as an alternative therapeutic option for the treatment of stage III colon cancer patients.

Hand-Assisted Laparoscopic Surgery for Colorectal Adenocarcinoma

Purpose. To report our preliminary result of hand-assisted laparoscopic surgery (HALS) for colorectal adenocarcinoma. Patients and Methods. From January 2002 to December 2003, eleven patients with colorectal adenocarcinoma underwent HALS, including 2 left hemicolectomies, 3 anterior resections and 6 low anterior resections. Outcome data analyzed included the operation time, blood loss, conversion to open procedure, length of specimen, time to return of flatus, length of postoperative hospital stay, complications, and recurrence. Results. There were 6 males and 5 females with an average age of 58.9years-old (range 21-87). The mean operative time was 184.1 mm (range 100-255). The mean estimated blood loss was 197.1 mL (range 100-800). The mean length of specimen was 14.3 cm (range 11-18). The mean days of first time to flatus were 3.1 days (range 2-4) and the mean hospital days were 10.5 days (range 6-29). There was no conversion to an open procedure but two postoperative complications developed, one was wound infection and the other was diarrhea with longer hospitalization. In the mean follow-up period of 23.4 months (range 11-31), there was no tumor recurrence but one mortality 6 months later due to other underlying medical problems. Conclusion. HALS might be a safe and feasible operation for colorectal adenocarcinoma.

Aggressive surgical resection of the primary tumor without metastasectomy first in stage IV colon cancer with unresectable synchronous liver-only-metastases patients cannot provide the survival benefits compared with chemotherapy first

Background: Controversy exists over whether aggressive surgical resection of the primary tumor without metastasectomy first or chemotherapy first in stage IV colon cancer with unresectable synchronous liver-only-metastases (CLM) improves patients. Materials and Methods: We retrospectively reviewed the outcome of 156 patients initially diagnosed with unresectable synchronous CLM who were under treatment in our institution from January 2004 to December 2012. Patients with extrahepatic diseases or previous hepatic resection were excluded. All patients with a follow-up of at least 3 months were included. Progression-free survival (PFS) and 5-year overall survival (OS) curves were calculated using the Kaplan–Meier method. Results: Among the 156 patients with CLM, 43 (27.56%) received aggressive surgical resection of the primary tumor without metastasectomy first, 113 (72.43%) received systemic chemotherapy first. At 5 years, the adjusted PFS and OS in stage IV colon cancer with inoperable metastases were 24.2% and 20.4%, respectively, in the surgical resection of the primary tumor first group and 46.0% and 16.9% in the chemotherapy first group (P = 0.515 and P= 0.742, respectively). In multivariate analysis, there was no statistical difference in the PFS and 5-year OS between the surgical resection of the primary tumor first group and chemotherapy first. Conclusion: Surgical resection of the primary tumor without metastasectomy first in CLM is not associated with improved survival as compared with chemotherapy first. Additional research is necessary to determine which patients may benefit from this intervention.

Laparoscopically Assisted Reversal of Hartmann's Procedure for Perforated Diverticulitis

The aim of this study was to retrospectively review the clinical outcomes of laparoscopically assisted and open surgical reversal of Hartmanns procedure (HR). We reviewed all patients undergoing l...

Short-term Outcome of ＂Watch and Wait＂ for Rectal Cancer with Clinical Complete Response after Neoadjuvant Chemoradiotherapy

Purpose. ＂Watch andWait＂ policy would be the option of treatment for locally advanced rectal cancer following chemoradiotherapy with clinical complete response The short-term outcome for ＂Watch andWait＂ has not been well established. The purpose of this work was to assess the shortterm outcome of non-operative strategies. Methods. This is an observational retrospective study of one institute. All of the patients with locally advanced rectal cancer following chemoradiotherapy with clinical complete response from January 1, 2007 to December 31, 2013 were included. Results. The study population consisted of 18 patients. 14 patients underwent transanal wide excision of primary lesion 8-12 weeks later after chemoradiotherapy, and the remaining 4 patients were left for only observation. Two local recurrences occurred in those undergoing transanal wide excision and were successfully treated by another transanal wide excision. Average disease-free period was 69.78 months, and 5 year-overall survival rate was 100%. CEA were within normal range in 3 years follow-up. Conclusions. ＂Watch andWait＂ policy offers good results in terms of survival and recurrence rates, and the policy could be be considered a therapeutic option in patients with locally advanced rectal cancer follwing chemoradiation therapy with complete clinical response.

The outcome of 5-fluorouracil chemotherapy after the completion of neoadjuvant chemoradiotherapy, administered until 2 weeks before rectal cancer resection

Background In most institutions, locally advanced rectal cancer is treated with neoadjuvant chemoradiotherapy followed by surgery 6–8 weeks later, allowing time for tumor response and recovery from chemoradiotherapy‐related toxicities. In our hospital, we continuously administer chemotherapy after the completion of chemoradiotherapy, until 2 weeks before surgery for most patients. Methods This was a retrospective study. Patients received a diagnosis of adenocarcinoma of the rectum at our hospital between January 2003 and December 2008 and received neoadjuvant chemoradiotherapy and curative surgery. Chemoradiotherapy consisted of continuous infusion of 225 mg/m2 5‐fluorouracil, 5 days per week. Radiation therapy was delivered at 1.8 Gy per day, 5 days per week for 5–6 weeks (median radiation dose, 50.4 Gy). Chemotherapy was continued until 2 weeks before surgery, and surgery was performed 6–8 weeks after completion of chemoradiotherapy. Results The study included 119 patients (median age, 61 years; range, 24–84 years). Twenty‐nine patients (24.4%) had a complete response and 65 (54.6%) had a partial response. Over a median follow‐up duration of 52 months, 10 patients experienced local recurrence and 18 had distant metastasis. The 5‐year overall and disease‐free survival rates were 80.6% and 72.9%, respectively. Grade 3–4 toxicity only occurred in 14 patients (11.8%). Conclusion Continued chemotherapy with 5‐fluorouracil after completing neoadjuvant chemoradiotherapy until 2 weeks before surgery for locally advanced rectal cancer results in a good pathological control rate, with low toxicity. Patients who achieved a complete pathological response had a better long‐term oncological outcome than those who did not.